Causes of premature labour

In more than 50% of cases the cause of preterm onset of labour is not known. The following are related with increased incidence of preterm labour :

A. History -

• Previous history of induced or spontaneous abortion or preterm delivery.
• Asymptomatic bacteriuria or recurrent urinary tract infection.
• Smoking habits.
• Low socio-economic and nutritional status.

Changes occur during 19th week of pregnancy

Baby's Development -

In this week baby is now covered with a white, waxy substance called vernix caseosa, which helps prevent delicate skin from becoming chapped or scratched. Premature babies may be covered in this cheesy coating at delivery. Baby is still tiny, but this week brings the development of brown fat, which will help keep baby warm after birth. During the last trimester, baby will add more layers of fat for warmth and protection.


Woman's Body -

Woman feels baby's movements, which often happens between weeks 18 and 20. These first movements are known as quickening, and they may feel like butterflies in stomach or a growling stomach. Later in pregnancy, woman will feel kicks, punches, and possibly hiccups. Each baby has different movement patterns. 

Many women wonder around this time whether having sex. Sex is considered safe at all stages of pregnancy, as long as pregnancy is normal. But that doesn't necessarily mean woman are going to want to have it. Many expectant women find that their desire for sex fluctuates during the various stages of pregnancy, depending on their fatigue, growing size, anxiousness over the birth, and a host of other body changes.


Related  Articles :

• Multiple pregnancy (Twins)
• What do you know about silent miscarriage (missed abortion)
• Antepartum haemorrhage
• Blood or Hematological changes during pregnancy
• Changes occur during 20th week of pregnancy

What is Premature or Preterm labour

Preterm labour is one where the labour starts before the 37th completed week (<259 days), counting from the first day of the last menstrual period. Preterm labour is also called premature labour. It starts more than three weeks before estimated date of delivery. 

Management of HIV infection in pregnancy

Prenatal care -

• All clients should be offered voluntary serologic testing for HIV infection.
• In seropositive cases additional investigation should be done to test for other STD's.
• Husband should be offered serological test for HIV.
• Counselling about the risk of HIV transmission to the fetus and neonates should be made and termination of pregnancy offered.
• Progressive of the disease is assessed by CD-4, T-lymphocyte count and HIV RNA.
• Assessment is done at every 3-4 months internal.

Care during intrapartum period - 

• Zidovudine is given IV infusion starting at the onset of labour (vaginal delivery) or 4 hours before caesarean section.
• Mechanical suctioning devices should be used to remove secretions from the neonates airways.
• Health care workers should be protected from contact with potentially infected body fluids.
• Disposable syringes and needles are used and they are deposited in the puncture proof containers.

Postpartum care -

• Mother must be counselled about risk and benefits of breast feeding and helped to make an informed choice.
• Zidovudine syrup 2 mg/kg is given to the neonates four time daily for first 6 weeks.
• Mother should be encouraged to manage the babies care herself with the support of midwife.
• Glove must be worn for examination the perineum, lochia and caesarean wound.
• Disposal of sanitary napkin and disinfection and cleaning of any spilled blood must be done correctly.

Contraceptive method -

Barrier method of contraception (condom or female condom) is effective in preventing transmission of virus. Thus the disease could be prevented predominantly by health education and by practice of safer sex.


Related Articles :

• HIV infection in pregnancy
• What is Intrauterine growth retardation (IUGR)
• Classification of hypertensive disorders in pregnancy
• Hyperemesis gravidarum during pregnancy
• Diagnosis of pregnancy in first trimester
• Changes occur during 20th week of pregnancy

HIV infection in pregnancy

HIV causes an incurable infection that leads ultimately to a terminal disease called AIDS which is a group retrovirus. Worldwide 25 - 30% of infected patients are woman and 90% of them are 22 - 49 of age.


Incidence -

Estimate at national level are that about 3.7 million people were suffering from HIV infection in most Asian countries. The infection rate is less than 0.5%.


Mode of transmission -

The mode of transmission of HIV are :

• Sexual contact.
• Exposure to infected blood or tissue fluid.
• Through breast milk.

HIV infection in pregnancy -

The transmission from mother to fetus is about 30% in seropositive mothers. The fetus may be affected through uteroplacental transfer during delivery by contaminated secretion and blood of the birth canal and through breast milk in the neonatal period.

Physical features of IUGR baby at birth

In IUGR (intrauterine growth retardation), the baby fails to grow at the expected rate during the pregnancy. After birth, the physical features of IUGR baby are following -

• Weight deficit at birth about 600 gm and below. Every hospital have their own birth weight-gestational age chart.
• Length is unaffected.
• Head circumference is relatively larger than the body.
• Physical features show dry and wrinkled skin because of less subcutaneous fat.
• The baby is alert, active and having normal cry, eyes are open.
• Reflexes are normal.

Related  Articles :

• What is Intrauterine growth retardation (IUGR)
• Causes of IUGR
• Causes of premature labour
• Multiple pregnancy (Twins)
• Causes of ectopic preganancy (Tubal pregnancy)
• Factors responsible for abortion
• Mechanism of birth
• Diagnosis of pregnancy in first trimester

Causes of IUGR

The causes of fetal growth restriction can be divided into four groups :

1. Maternal

2. Fetal

3. Placental

4. Unknown

Maternal -

• Small woman have small babies. These babies are not at increased risk.
• Maternal nutrition before and during pregnancy -: As most of the fetal weight gain occurs behind 24th week of pregnancy. Malnutrition, anemia and oxygen deficiency during significant role in the reduction of the birth weight.
• Toxins -: Alcohol, smoking, cocaine, heroine, drugs.
• Maternal diseases -: Anemia, hypertension, heart disease, chronic renal failure.

What is Intrauterine growth retardation (IUGR)

IUGR is said to be present in those babies whose birth weight is below the 10th percentile of the average for the gestational age. In other way, it is poor growth of a baby in the mother's uterus during pregnancy.


Incidence - 

The incidence among term babies is about 5% and that among post term babies is about 15%.


Types -

Based on clinical evaluation and ultrasound examination the fetuses are divided into two types :

• Fetuses that are small and healthy -                                                                          The birth weight less than 10th percentile for the gestational age. They have normal subcutaneous fat and usually uneventful neonatal course. 

• Fetuses where growth is restricted by pathological process (true IUGR) -                   Depending upon the relative size of their head, abdomen and femur. The fetuses are subdivided into two types :

What is Superfetation and Superfecundation

Superfetation - 
Superfetation is the fertilization of two ova released in different menstrual cycles. Ovulation is usually suspended during pregnancy time to prevent chance of fertilization of other ova. If an ovum is released after the female was already pregnated, there is a chance of second pregnancy. This is called superfetation. The nidation and development of one fetus over another fetus is theoretically possible until the decidual space is obliterated by 12 weeks of pregnancy.

Management of twin pregnancy

Early management of twin pregnancy is important to prepare the parents by giving the special and advice. This will help to mother to take additional care not only for her own benefit also for the fetuses.

Advice -

• Diet – Increased dietary supplement is needed for increased energy supply to the extent of 300 Kcal per day, over and above that needed in a single pregnancy.

• Rest – Increased risk at home and early cessation of work is advised to prevent preterm labour and other complications.

• Supplement – Additional vitamins, calcium and folic acid are to be given, over and above those prescribed for a singleton pregnancy.

• More antenatal visit should be advised.

• Fetal growth assessment must be done at 2-3 week.

Hospitalization –

The woman may be admitted around the 32^nd week if she prefers it. This result in increase birth weight of babies, decreased frequency of preeclampsia, decrease frequency of preterm labour and lowered perinatal mortality.

Causes of genesis of twins

The exact cause of twinning is not known. The frequency of monozygotic twins remains constant through the globe and is probably related to maternal environmental factors. It is the wide variation in the prevalence of dizygotic twins which is responsible for the fluctuation in the overall incidence of twins in different populations. Possible causes are following :

1. Superfetation is the fertilization of two ova released in different menstrual cycles. The nidation and development of one fetus over another fetus is theoretically possible until the decidual space is obliterated by 12 weeks of pregnancy.                                                                                                                                                

Description of genesis of twins

                                  Genesis of twins

A. Dizygotic twins - 

Dizygotic twins results from fertilization of two ova, most likely ruptured from two distinct graafian follicles usually of the same or one from each ovary, by two sperms during a single ovarian cycle. Their subsequent implantation and development differ little from those of a single fertilized ovum.

B. Monozygotic twins (identical) -

The twinning may occur at different periods after fertilization and this markedly influences the process of implantation and the formation of the fetal membranes. After the fertilization, the following possibilities may occur -

• If the division takes place within 72 hours after fertilization (prior to morula stage) the resulting embryos will have two separate placenta, chorions and amnions (diamniotic - dichorionic or D/D)

• If the division take place between the 4th and 8th day after the formation of inner cell mass when chorion has already developed - diamniotic monochorionic twins develop (D/M).

• If the division occur after 8th day of fertilization when the amniotic cavity has already formed, a monoamniotic - monochorionic twins develops (M/M).

• Rare occasion, division occurs after two weeks of the development of embryonic disc resulting in the formation of conjoined twins called siamese twins. Four types of fusion may occur -

       i) Thoracopagus - conjoined twins at the thorax.

       ii) Pyopagus - conjoined twins at the posterior site.

       iii) Craniopagus - twins joint at the head.

       iv) Ischiopagus - twins joint at the ischeum.


Related articles :

• Multiple pregnancy (Twins)
• Causes of genesis of twins
• Management of twin pregnancy
• What is Superfetation and Superfecundation

Multiple pregnancy (Twins)

When more than one fetus simultaneously develops in the uterus, it is called multiple pregnancy. Simultaneous development of two fetuses (twins) is the commonest. Although rare, development of three fetuses (triplets), four fetuses (quadraplets), five fetuses (quintuplets) or six fetuses (sextuplets) may also occur.

                                                 Twins 

Definition - 

Simultaneous development of two fetuses in the uterus is the commonest variety of multiple pregnancy.


Varieties -

i) Dizygotic twins - It is the commonest (2/3) and result from the fertilization of two ova.

ii) Monozygotic twins - It is rare (1/3) result from the fertilization of a single ovum.


Related articles :

• Description of genesis of twins
• Causes of genesis of twins
• What is Superfetation and Superfecundation
• Management of twin pregnancy

Treatment of eclampsia

The patient if at home or in peripheral health centres, should be shifted urgently to the referral hospital. The aim of immediate management in the hospital are :

• Clear and maintain the airway.
• Prevent injuries.
• Prevent hypoxia.
• Arrest convulsions.

General management -

- The patient should be placed in a railed cot in an isolated room, protected from 
   noxious stimuli which might provoke further fits.
- Detailed history is to be taken from the relatives, relevant to the diagnosis of 
   eclampsia, duration of pregnancy and number of fits.
- When the patient is properly stabilized, general abdominal and vaginal examination 
   are done.
- If the patient is unconscious, catheter is introduced and urine is tested for protein.
- Pulse, respiration and BP should be recorded half hourly.
- Fluid balance- Ringer's solution is started.
  Total fluids = Previously 24 hours urinary output + 1000 ml (insensible loss through 
   lungs and skin).

Four stages of convulsion or fits

Eclamptic convulsion or fits are epileptiform and consist of four stages :

Premonitory stage -

The patient becomes unconscious. There is twitching of the muscles of the face, tongue and limbs. Eye ball roll or are turned to one side and become fixed. This stage lasts for about 30 seconds.

Tonic stage -

The whole body goes into a tonic spasm - the trunk-opisthotonus, limbs are flexed and hand clenched. Respiration ceases and the tongue protrudes between the teeth. Cyanosis appears. Eye balls become fixed. This stage lasts for about 30 seconds.

Difference between eclampsia and preeclampsia

Preeclampsia -

Preeclampsia is a multi system disorder of unknown etiology characterized by development of hypertension to the extent of 140/90 mm Hg or more with proteinuria after the 20th week in a previously normotensive and non-proteinuric patient.

About 5-8% of all pregnancies are complicated with preeclampsia. Abnormal or rapid weight gain and edema over ankles are the main alarming sign and symptoms.

Eclampsia -

Preeclampsia when complicated with convulsion and/or coma is called eclampsia. Convulsion or fits are consist of four stages- premonitory, tonic, clonic and stage of coma. Mostly 50% fits occur during antepartum period (before the onset of labour).


Related Articles :

• Treatment of eclampsia
• Four stages of convulsion or fits

Classification of hypertensive disorders in pregnancy

Hypertension is a common disorder of pregnancy. Hypertension may appear for the first time during pregnancy as a direct result of the gravida state.

Classification of hypertensive disorders in pregnancy :-

A. Pregnancy induced hypertension (PIH) -

   1. Gestational hypertension - without protein-urea or pathological edema.
                    2. Preeclampsia - hypertension and protein-urea with or without edema.
                         3. Eclampsia - preeclampsia complicated with convulsion and/or coma.

What is cervical pregnancy ?

It is occurs due to implantation of the fertilized ovum in the cervical canal. It may be due to rapid passes of fertilized ovum or fertilization of the ovum after it reaches in the cervical canal. The morbidity and mortality is high because of profuse haemorrhage.

Sign and symptoms -

• Painless bleeding after the time of implantation.
• Thinning of the cervical wall.
• Dilatation of the external Os (opening of cervix).

Treatment -

Sonography reveals the pregnancy in the cervical canal and an empty uterine cavity. The treatment is removal of the product of conception by curettage. Hysterectomy is often required to stop bleeding.


Related Articles :

• How abdominal pregnancy occurs ?
• Causes of ectopic preganancy (Tubal pregnancy)
• What are the early symptoms of pregnancy ?

How abdominal pregnancy occurs ?

Abdominal pregnancy is rare. A primary abdominal ectopic pregnancy is the result of implantation of the fertilized ovum on the peritoneal surface. A secondary abdominal pregnancy forms when an embryo expelled through rupture or abortion of a tubal pregnancy. The embryo does not died because of its chorionic attachment to the uterine tube and grows by forming attachment to the pelvic peritoneum, intestine etc.
                   The fetus grows in the peritoneal cavity but the majority of these pregnancy do not survive. If the fetus die early in pregnancy, it may be reabsorb.

If pregnancy is continue following symptoms are appears -

• Lower abdominal pain.
• Nausea and vomiting.
• Constipation or/and diarrhoea.
• Urinary frequency.

Abdominal pregnancy is treated or delivered by laparotomy (It is a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity).

What are the early symptoms of pregnancy ?

Every woman is different, so they experience different symptoms of pregnancy. Not every woman has the same symptoms. Some of the most common early symptoms of pregnancy are described following. These symptoms may be caused by other things besides being pregnant. So the fact that some of these symptoms does not necessarily mean pregnancy. It is only confirmed by a pregnancy test.

Spotting and Cramping - 

- A few days after conception the fertilized egg attaches itself to wall of the uterus. This can cause
  one of the earliest signs of pregnancy spotting and cramping.
- That's called implantation bleeding. It occurs anywhere from 6 to 12 days after the egg is
  fertilized.
- The cramps resemble menstrual cramps, so some women mistake them and the bleeding for the
  start of their period. The bleeding and cramps are slight.

- Besides bleeding, a woman  may notice a white, milky discharge from her vagina. That's related
  to the thickening of the vagina's walls. The increased growth of cells lining the vagina causes the
  discharge.

- This discharge, which can continue throughout pregnancy, is typically harmless and doesn't
  require treatment.

Breast Changes -

Breast changes are very early sign of pregnancy. A woman's hormone levels rapidly change after conception. Because of the changes, her breasts may become swollen a week or two later. They may feel heavier or fuller or feel tender to the touch. The area around the nipples, called the areola, may also darken.

Causes of ectopic preganancy (Tubal pregnancy)

An ectopic pregnancy is one in which the fertilized ovum is implanted and develops outside the normal uterine cavity. Ectopic pregnancy still contributes significantly to the cause of maternal mortality and morbidity.

Causes :-

- Factors preventing or delaying the migration of the fertilized ovum to the uterine cavity.
- Factors facilitating nidation of the fertilized ovum in the tubal mucosa.

1. Factors preventing or delaying migration -

• Pelvic inflammatory disease (PID) increases the risk of ectopic pregnancy.
• Selected contraception failure.
• Use of intrauterine device.
• Tubal surgery increase the risk of tubal pregnancy.
• Intrapelvic adhesion following pelvic surgery.
• Prior induced abortion significantly increases the risk.

2. Factors facilitating nidation in the tube -

• Early resumption of the trophoblastic activity is probably due to premature degeneration of the zona pellucida.
• Increased decidual reaction.
• Tubal endometriosis.

What is bearing down efforts during labour

It is the additional voluntary expulsive efforts that appear during the second stage of labour (expulsive stage). It is initiated by nerve reflex set up due to stretching of the vagina by the presenting part. In majority, this expulsive effort start spontaneously with full dilatation of the
cervix. It helps in passing the baby through birth canal.
                    Along with the uterine contraction, the woman is instructed to exert downward pressure as done during straining at stool. Sustained pushing beyond the uterine contraction is discouraged. In the first stage of labour, bearing down efforts may suggest uterine dysfunction. There may be slowing of the fetal heart rate during pushing and it should come back to normal once the contraction is over.

Pain during labour

The first symptom to appear is intermittent painful uterine contractions followed by expulsion of blood stained mucus (show) per vaginam. Only few drops of blood mixed with mucus is expelled and any excess should be considered abnormal.
                               The pains are felt more anteriorly with simultaneous hardening of the uterus which is bodily pushed forwards. Initially, the pains are not strong enough to cause discomfort and come at varying intervals of 15-30 minutes with duration of about 30 sec. But gradually the interval becomes shortened with increasing intensity and duration so that in late first stage the contraction comes at intervals of 3-5 minutes and lasts for about 45 sec. The relation of pain with uterine contraction is of great clinical significance.
                                In normal labour, pains are usually felt shortly after the uterine contractions begin and pass off before complete relaxation of the uterus. Clinically, the pains are said to be good if they come at intervals of 3-5 minutes.

Role of gravity after childbirth

After the childbirth gravity play important role. Soon after the delivery of the baby, it should be placed on a tray covered with clean dry linen with the head slightly downwards (about 15 degree downward).

• It facilitates drainage of the mucus accumulated in the trachco-bronchial tree by gravity. 
• The tray is placed between the legs of the mother and should be at a lower level than the uterus to facilitate gravitation of blood from the placenta to the infant.

How the baby's head comes out during labour

The body of uterus, cervix and vagina together form an uniformly curved canal called the birth canal. Normally, at the onset of labour with the head non-engaged, the pelvic structures anterior to the vagina are urethra and bladder and those posterior to the vagina are the pouch of Douglas with coils of intestine, rectum anal canal and perineum.
                                    As the head descends down with progressive dilatation of the vagina, it displaces the anterior structures, upwards and forwards and the posterior structures downwards and backwards, as if the head is passing through a swing door. The bladder which remains a pelvic organ throughout the first stage becomes an abdominal organ in the second stage of labour. There is no stretching of the urethra. The urethra is pushed anteriorly, with the neck of the bladder still lying in the vulnerable position behind the symphysis pubis. The changes in the posterior structures due to downward and backward displacement are marked when the head is sufficiently low down and in the stage of 'crowing'. The perineum which is a triangular area of about 4 cm thickness becomes a thinned out, membranous structure of less than 1 cm thickness. The anus, from being a closed opening, becomes dilated to the extent of 2-3 cm. The canal becomes almost a semicircle.

Suction evacuation and curettage

It is a procedure in which the product of conception are sucked out from the uterus with the help of a cannula fitted to a suction apparatus. This improvised method consists of a suction machine fitted with a cannula either plastic or metal available in various sizes.

Indications -

• Medical termination of pregnancy during first trimester (commonest).
• Inevitable abortion
• Recent incomplete abortion
• Hydatidiform mole

Advantages - 

• It is an outdoor procedure.
• Ideal for termination of therapeutic indications.
• Blood loss is minimal.
• Chance of uterine perforation is much less.

Disadvantages - 

• The method is not suitable with bigger size uterus.
• Requires electricity to operate and the machine is costly.

Induced abortion or termination of pregnancy

Induction of abortion -
Deliberate termination of pregnancy before the viability of the fetus is called induction of abortion. The induced abortion may be legal or illegal (criminal). There are many countries in the globe where the abortion is not yet legalized.

Indications -
- Maternal disease such as heart disease, severe hypertension etc.
- Pregnancy caused by rape.
- Contraceptive failure pregnancy.
- Poor multiple with unplanned pregnancy.
- Eugenic indication such as down syndrome.
- Pregnancy caused as a result of failure of a contraceptive.

Methods of termination of pregnancy -

First trimester (upto 12 weeks) :-
Surgical -

• Manual vacuum aspiration
• Suction evacuation and/or curettage
• Dilatation and evacuation

Medical -

• Mifepristone
• Mifepristone and Misoprostal
• Methotrexate and Misoprostol

Second trimester (13-20 weeks) :-

• Dilatation and Evacuation
• Intrauterine instillation of  hyperosmotic solutions
• Prostaglandins
• Oxytocin infusion
• Hysterotomy - less commonly done.

Continuous miscarriage (Recurrent miscarriage)

Recurrent miscarriage is defined as a sequence of three or more consecutive spontaneous abortion before 20 weeks. A woman procuring three consecutive induced abortion is not a habitual abortion.

Causes - 
The causes of recurrent abortion are complex and most often obscure. More than one factor may operate in a case. Factors may be recurrent or non-recurrent. There are known specific factors which are responsible for early or late abortion and they are following:
- Genetic factors
- Endocrine and metabolic disorders
- Infection
- Inherited thrombophilia
- Immunological causes such as autoimmune and alloimmune disorder
- Cervical incompetence

Septic abortion

Any abortion associated with clinical evidence of infection of the uterus and its contents, is called septic abortion. The micro-organisms involved in the sepsis are usually those normally present in the vagina, such as anaerobic streptococci, tetanus bacillus, E.coli etc.

Clinical features -

• Pyrexia
• Pain
• A rising pulse rate - 100-120/ min or more
• Internal examination reveals offensive purulent vaginal discharge.

Clinical grading -
Grade 1 :- The infection is localized in the uterus.
Grade 2 :- The infection spreads beyond the uterus to the parametrium, tubes and ovaries or
                 pelvic peritoneum.
Grade 3 :- Generalized peritonitis and/or endotoxic shock or jaundice or acute renal failure.

Investigation -

• Ultrasonography (USG)
• Urine analysis including culture
• Cervical or high vaginal swab is taken for culture in aerobic and anaerobic media.

Complications -

Immediate :-

- Haemorrhage related to abortion process and also due to the the injury.

- Generalized peritonitis.

- Endotoxic shock.

- Acute renal failure.

- Thrombophlebitis.

Remote :-

- Dyspareunia.

- Ectopic pregnancy.

- Secondary infertility due to tubal blockage.

- Emotional depression.

Prevention - 

• To boost up family planning.
• To prevent unwanted pregnancy.
• To take antiseptic and aseptic precautions either during internal examination or during operation in spontaneous abortion.

Management -

General management :-

- Hospitalization is essential for all cases of septic abortion.

- To take high vaginal or cervical swab for culture and drug sensitivity.

- Vaginal examination is done to note the state of abortion process and extension of the infection.

- Investigation protocols are outlined.

- Principle of management is to control sepsis and remove the source of infection.

What is blood mole abortion

Blood mole -

In missed abortion, the clotted blood with the contained ovum is known as a blood mole. By this time, the ovum becomes dead and is either completely absorbed or remains as a rudimentary structure. Gradually, the fluid portion of the blood surrounding the ovum gets absorbed and the wall becomes fleshy, hence the term fleshy or carneous mole.

What do you know about silent miscarriage (missed abortion)

When the fetus is dead and retained inside the uterus for a variable period, it is called missed abortion or silent miscarriage. The cause of prolonged retention of the dead fetus in the uterus is not clear. Beyond 12 weeks, the retained fetus becomes macerated. The liquor amnii gets absorbed and the placenta becomes pale thin and may be adherent. Before 12 weeks, the pathological process differs when the ovum is more or less completely surrounded by the chorionic villi.

Clinical features -
- Continuation of pain in lower abdomen.
- Persistence of vaginal bleeding.
- Brownish vaginal discharge.
- Non audibility of fetal heart sound.
- Absence of fetal motion.
- Immunological test for pregnancy becomes negative.

Management -

Uterus is less than 12 weeks :- 

Vaginal evacuation can be carried out without delay. This can be effectively done by suction evacuation or slow dilatation of the cervix by laminaria tent followed by dilatation and evacuation
(D & E) of the uterus under general anaesthesia.

Uterus more than 12 weeks :- 
i) Oxytocin - To start with 10-20 units of oxitocin in 500 ml of normal saline.
ii) Prostaglandins - It is more effective than oxytocin in such cases. Prostaglandin Ei analogue (misoprostol) tablet is inserted into the posterior vaginal fornix every 4 hours for a maximum 5 times.

What is incomplete abortion

When the entire product of conception are not expelled, instead a part of it is left inside the uterine cavity, it is called incomplete abortion.

Clinical features -
- Continuation of pain lower abdomen.
- Persistence of vaginal bleeding.
- On examination, the expelled mass is found incomplete.
The products left behind may lead to profuse bleeding, sepsis, placental polyp.

Management -

• Early abortion :- Dilatation and evacuation under general anaesthesia.
• Late abortion :- The uterus is evacuated under general anaesthesia and the products are removed by ovum forceps or by blunt curette.

Complete abortion

When the products of conception are expelled completely with masse, it is called abortion.

Clinical features -
- Subsidence of abdominal pain.
- Vaginal bleeding becomes trace or absent.
- Cervical os (opening) is closed.

Management -
a) The effect of blood loss should be assessed and treated. If there is double about complete expulsion of the products, uterine curettage should be done.
b) Transvaginal sonography is useful to prevent unnecessary surgical procedure.

Inevitable abortion

It is the clinical type of abortion where the changes have progressed to a state from where continuation of pregnancy is impossible.

Clinical features -
- Increased vaginal bleeding.
- Pain in the lower abdomen.
- Internal examination reveals dilated internal opening of cervix.

Management -

General measures :-
- Excessive bleeding should be controlled by administering methergin 0.2 mg.
- The shock is corrected by I.V. fluid therapy and blood transfusion.

Active management :-
1. Before 12 weeks - Dilation and evacuation followed by curettage of the uterine cavity by blunt curette under general anaesthesia. Alternatively, suction evacuation followed by curettage is done.

2. After 12 weeks - The uterine contraction is acceleration by oxytocin drip. If bleeding is profuse with the cervix closed evacuation of the uterus may have to be done by abdominal hysterotomy.

What is threatened abortion

It is a clinically entity where the process of abortion has started but has not progressed to
a state from which recovery is impossible.

Clinical features -
1. Bleeding :- The bleeding is usually slight and bright red in colour.
2. Pain :- Pain appears usually following haemorrhage.

Investigation - 
Ultrasonography is helpful in observation of fetal status.

Treatment - 
Rest :- 
The patient should be in bed for few days until bleeding stops.

Drugs :- 
Sedation and relief of pain may be ensured by phenobarbitone 30 mg or diazepam 5 mg
tablet twice daily.

General measures :- 
- The patient is advised to preserve the vulval pads and anything expelled out per vaginum,
  foor inspection.
- To report if bleeding or pain.
- Routine note of pulse, temperature and vaginal bleeding.

Advice on discharge -

• The patient should limit her activities for at least two weeks.
• Avoid heavy work.
• Coitus is contraindicated during this period.

Types of abortion

Abortion is the expulsion or extraction from its mother of an embryo weighting 500 gm or less when it is not capable of independent survival. It is mainly divided into two types -
1. Spontaneous abortion
2. Induced abortion

Spontaneous abortion - It is divided in following types:

• Threatened abortion
• Inevitable abortion
• Complete abortion 
• Incomplete abortion 
• Missed abortion
• Septic abortion

Induced abortion - It has two types:

• Legal abortion - Medical termination of pregancy (MTP)
• Illegal (criminal) abortion

Factors responsible for abortion

1. Endocrine and metabolic factors -
Luteal phage defect (LPD) results in early miscarriage as implantation and plancental are not supported adequately. Deficient progesterone secretion from corpus luteum or poor endometrial response to progesterone is the cause. Diabetes mellitus when poorly controlled, causes increased miscarriage.

2. Anatomical abnormalities - 
These are related mostly to the second trimester abortions.
- Cervical incompetance.

- Congenital malformation of the uterus is cause of fetal loss.

- Reduced intrauterine volume.

- Increased uterine irritability and contraction.

- Intrauterine adhesions interfere with implantation, placental and fetal growth.

3. Infections -

Infections are accepted causes of late as well as early abortions. Infections could be :

i) Viral :- Rubella, HIV.

ii) Parasitic :- Toxoplasma, malaria.

iii) Bacterial :- Chlamydia, brucella.

4. Immunological disorders

5. Environmental factors

6. Genetic factors

7. Others -

- Maternal medical illness.

- Cyanotic heart disease (CHD).

- Blood group incompatibility.

- Premature rupture of membranes.

- Inherited thrombophilia.

Immunological disorders are responsible for abortion

Both autoimmune and alloimmune factors can cause miscarriage.

• Autoimmune disease :- It can cause miscarriage usually in the second trimester. These patient form antibodies against their own tissue and the placenta. These antibodies ultimately cause rejection of early pregnancy. placental thrombosis, infarction and fetal hypoxia is the ultimate pathology of cause abortion.

• Alloimmune disease :- Paternal antigens which are foreign to the mother invoke a protective blocking antibody response. These blocking antibodies prevent maternal immune cells from recognising the fetus as a foreign entity. Therefore, the fetal allograft containing foreign paternal antigens are not rejected by the mother. Paternal human leukocyte antigen (HLA) sharing with the mother lead to diminished fetal-maternal immunologic interaction and ultimately fetal rejection (abortion).

How environmental factor is responsible for abortion

Smoking -
Cigarette smoking increases the risk due to formation of carboxy haemoglobin and decreased oxygen transfer to the fetus. Alcohol consumption should be avoided or minimized during pregnancy.

X-Irradiation and antineoplastic drugs are known to abortion. X-ray exposure is a risk of abortion,
so it is avoided or minimized in the pregnancy period.

Contraceptive agents -
IUD (Intrauterine device) increases the risk whereas oral pill do not.

Drugs, chemicals and noxious agents -
Anaesthetic gases, arsenic, lead, formaldehyde increases the risk.

Miscellaneous - 
Exposure to electro-megnetic radiation from video display terminals does not increase the risk. Woman can safely use hair dyes, watch television and fly in airlines during pregnancy.

How the genetic factor is responsible for abortion

Majority (50%) of early miscarriage are due to chromosomal abnormality in the conceptus.

Autosomal trisomy is the commonest cytogenetic abnormality about 50%. Trisomy for 

every chromosome except chromosome 1 has been reported. 

Trisomy 16 is the most common trisomy in human pregnacies, occuring in more than 

1% of pregnancies. Only those pregnancies in which some normal cells occur in addition 

to the trisomy cells, survive. This condition usually results in spontaneous miscarriage in 

the first trimester. 

Structural chromosomal rearrangements are observed in 2-4% of abortuses.  These includes 

translocation, deletion, inversion and ring formation. Other chromosomal abnormalities 

like mosaic, double trisomy etc are found in about 4% of abortuses.

Mechanism of abortion process

In the early weeks, death of the ovum occurs first, followed by its expulsion. In later weeks, maternal environmental factors are involved leading to expulsion of the fetus which may have signs of life but is too small to survive.

• Before 8 weeks :- The ovum, surrounded by the villi with the decidual coverings, is expelled out intact. Sometimes, the external opening of cervix fails to dilate so that the entire mass is accommodated in the dilated cervical canal and is called cervical abortion.

• 8-14 weeks :- Expulsion of the fetus commonly occur leaving behind the placenta and the membranes. A part of it may be partially separated with brisk haemorrhage or remains totally attached to the uterine wall.

• Beyond 14th week :- The process of the expulsion is similar to that of a ''mini labour''. The fetus is expelled first followed by expulsion of the placenta after a varying interval.

What is spontaneous abortion (miscarriage)

According to WHO ''Abortion is the expulsion or extraction from its mother of an embryo
or fetus weighting 500 gm or less when it is not capable of independent survival.''
This 500 gm of fetal development is attained approximately at 22 weeks of gestation.
The expelled embryo or fetus is called abortus. The term miscarriage, which is mostly used,
is synonymous with spontaneous abortion.

Incidence -: 10-20% of all clinical pregnancies.

Common causes of abortion -

In first trimester :-

• Genetic factors
• Endocrine disorders
• Immunological disorders
• Infection

In second trimester :-

• Anatomical abnormalities
• Cervical incompetence
• Maternal medical illness
• Unexplained

Haemorrhage in early pregnancy

In early pregnancy, woman might get some light bleeding called 'spotting', when the foetus 
plants itself into the wall of uterus. This is also known as implantation bleeding and it often 
occurs after the missed period.

During the first three months of pregnancy, vaginal bleeding can be a sign of miscarriage or 
ectopic pregnancy (when the foetus starts to grow inside fallopian tubes instead of womb). 
Most miscarriages occur during the first 12 weeks of pregnancy and, most cannot be prevented. 

The causes of bleeding in early pregnancy are broadly divided into two groups.

• Those related to pregnant state :- This group relates to abortion (95%), ectopic pregnancy and implantation bleeding.
• Those associated with pregnant state :- The lesions are unrelated to pregnancy. Cervical lesions such as vascular erosion, polyp, ruptured varicose vein and malignancy are important causes.

Abruptio placentae (Early separation of placenta)

Abruptio placenta is defined as one form of antepartum haemorrhage where the bleeding
occurs due to premature separation of normally situated placenta. It is also called
placental abruption.

Varieties -
1. Revealed - Following separation of the placenta, the blood insinuates downwards
between the membranes and the decidua. Ultimately, the blood comes out of the cervical
canal to be visible externally. This is the commonest type.

2. Concealed - The blood collects behind the separated placenta or collected in between
the membranes and decidua. The collected blood is prevented from coming out of the
cervix by the presenting part which presses on the lower segment. At this times,
the blood may percolate into the amniotic sac after rupturing the membranes. In any of
the circumstances blood is not visible outside. This type is rare.

3. Mixed - In this type, some type of the blood collects inside (concealed) and a part is
expelled out (revealed).

Incidence - The overall incidence is about 1 in 150 deliveries.

Etiology -
- Hypertension in pregnancy.
- Trauma.
- Sudden uterine decompression.
- Short cord.
- Sick cord.
- Folic acid deficiency.
- cocaine abuse.

Clinical classification -

Depending upon the degree of placental abruption and its clinical effects, clinical classification 

is as follows:

Class 0 (Asymptomatic) - characteristics include the following:

• - Clinical feature may be absent.
• - The diagnosis is made after inspection of placenta following delivery.

Class 1 (Mild) - characteristics include the following:

• - External bleeding is slight.
• - Slightly tender uterus.
• - Normal maternal BP and heart rate.
• - No fetal distress.

Class 2 (Moderate) - characteristics include the following:

• - Vaginal bleeding mild to moderate.
• - Uterine tenderness is always present.
• - Maternal tachycardia.
• - Fetal distress.
• - Shock is absent.

Class 3 (Severe) - characteristics include the following:

• - Bleeding is moderate to severe or may be concealed.
• - Very painful tetanic uterus.
• - Maternal shock is pronounced.
• - Fetal death.
• - Shock is pronounced.

Sign and symptoms -

- Dark red bleeding.

- Abdominal pain and bleeding.

- Shock.

- PIH (pregnancy induced hypertension).

- Anemia.

- Pre-eclampsia.

- Uterine tenderness and hard.

- Low Hb level.

- Headache and vomiting may be present.

Management - 

Prevention -

- To detect the causes which produce placental separation. 

- To minimize and correct the anemia during antenatal period.

- Avoidance of trauma.

- To avoid sudden decompression of the uterus.

- Routine administration of folic acid.

Cause of bleeding in placenta previa

As the placenta growth slows down in later months and the lower segment
progressively dilates, the inelastic placenta is sheared off the wall of the lower
segment. This leads to opening up to utero-placental vessels and leads to an 
episode of bleeding. As it is a physiological phenomenon which leads to the
separation of the placenta, the bleeding is said to be inevitable. However,
the separation of the placenta may be provoked by trauma including vaginal
examination, coital act, external version or during high rupture of the membranes.
The blood is almost always maternal, although fetal blood may escape from the
torn villi specially when the placenta is separated during trauma.

The mechanisms of spontaneous control of bleeding are :
1. Thrombosis of the open sinuses.
2. Mechanical pressure by presenting part.
3. Placental infarction.

Cause of implantation of placenta in lower uterine segment

The exact cause of implantation of the placenta in the lower segment is not known.
The following theories are postulated :

1. Dropping down theory - The fertilized ovum drops down and is implanted in the
lower segment. Poor decidual reaction in the upper uterine segment may be the cause.
This explains the formation of central placenta praevia.

2. Defective decidua, resulting in spreading of the chorionic villi over a wide area in
the uterine wall to get nourishment. During this process, not only the placenta becomes
membranous but encroaches onto the lower uterine segment.

3. The formulation of capsular placenta - For chorion coming in contact with decidua
vera of the lower segment.

4. Big surface area of the placenta as in twins may encroach onto the lower segment.

The predisposing factors for placenta praevia -
- Multiparity.
- Increased maternal age (more than 35 years).
- History of previous caesarean section.
- Placental size.
- Smoking causes placental hypertrophy.

Placenta previa (Implantation of placenta in lower uterus)

When the placenta is implanted partially or completely over the lower uterine segment,
it is called placenta previa. When the inelastic placenta sheared off by the dilation of
lower uterine segment for expulsion of fetus, leads to bleeding.

Incidence - 1 in 200 deliveries in the hospital.

Cause -
The exact cause of implantation of the placenta in the lower segment is not known.
It is more common in women who have:
- Abnormally shaped uterus 
- Many previous pregnancies
- Multiple pregnancy (twins, triplets, etc.)
- Due to history of surgery, c-section, previous pregnancy, or abortion.

Women who smoke or have their children at an older age may also have an increased risk.

Types or degrees -
There are 4 types of placenta previa depending upon the degree of extension of placenta
to the lower segment.

1. Type I (low lying) - The major part of the placenta is attached to the upper segment
   and only the lower margin encroaches to the lower segment but not upto the cervical
   os (opening).

2. Type II (marginal) - The placenta reaches the marginal of the internal os but not cover it.

3. Type III (incomplete or partial central) - The placenta cover the internal os partially.

4. Type IV (central or total) - The placenta completely covers the internal os even after
    it is fully dilated.

Symptoms -
The only symptoms of placenta previa is vaginal bleeding. The classical features of bleeding
are sudden onset, painless, apparently causeless and recurrent.

Diagnosis -
This condition is diagnosed by ultrasonography.

Antepartum haemorrhage

It is defined as bleeding from or into the genital tract after the 28th week of pregnancy but before the birth of baby. The first and second stage of labour are thus included. The 28th week is taken arbitarily as the lower limit of fetal viability.

Causes -
The causes of antepartum haemorrhage fall into the following categories. On an average, the incidence of placenta praevia, abruptio placentae and indeterminate group is almost same.

Effect of excessive vomiting in pregnancy

1. Metabolic changes -
- Inadequate intake of food results in glycogen depletion. For the energy supply, the fat
  reserve is broken down.
- Due to low carbohydrate, there is incomplete oxidation of fat and accumulation of ketone
  bodies in the blood.
- The acetone is ultimately excreted through the kidneys and in the breath.
- There is also increase in endogenous tissue protein metabolism resulting in excessive
  excretion of non-protein nitrogen in the urine.
- Water and electrolyte metabolism are seriously affected leading to biochemical and
  circulatory changes.

2. Biochemical changes - 
- Loss of water and salts in the vomitus resulting in fall in plasma sodium, potassium
  and chlorides.
- The urinary chloride may be well below the normal 5 gm/litre or may even be absent.
- Hepatic dysfunction results in acidosis and ketosis with rise in blood urea and uric acid ,
  hypoglycaemia, hypoproteinaemia, and hypovitaminosis.

3. Circulatory changes - 
There is haemoconcentration leading to rise in haemoglobin percentage, RBC count and
haematocrit values. There is slight increase in the white cell count with increase in eosinophils.
There is concomitant reduction of extracellular fluid.

Hyperemesis gravidarum during pregnancy

It is a severe type of vomiting of pregnancy which has got deleterious effect on the health 
of the mother and/or incapacitates her in day to day activities.

Incidence - Less than 1 in 1000 pregnancy.

Etiology -
The etiology is obscure but the following are the known facts :
- It is mostly limited to the first trimester.
- It is more common in first pregnancy.
- It has got a familial history -mother and sister also suffer from the same manifestation.
- It is more prevalent in multiple pregnancy.
- It is more common in unplanned pregnancies.

Causes -
The exact causes are not known. There are some theories for hyperemesis gravidarum.
1. Hormonal - Progesterone excess leading to relaxation of the cardiac sphincter and
    simultaneous retention of gastric fluids due to impaired gastric motility.
2. Psychogenic - It probably aggravates the nausea once it begins. But neurogenic element
    sometimes plays a role, as evidenced by its subsidence after shifting the patient from the
    home surroundings.
3. Dietary deficiency - Probably due to low carbohydrate reserve, as it happens after a night
    without food.
4. Allergic or immunological basis.
5. Decrease gastric motility is found to cause nausea.

Sign and symptoms -
- Dry coated tongue.
- Sunken eyes.
- Acetone smell in breath.
- Tachycardia.
- Hypotension.
- Rise in temperature.
- Oliguria.
- Epigestric pain.
- Constipation.

Management -
Principles -
- To control vomiting.
- To correct the fluids and electrolytes.
- To prevent or to detect complications at earliest stage.

Hospitalization - 
Whenever a patient is stamped as a case of hyperemesis gravidarum, she is admitted in hospital.

Fluids - 
Oral feeding is withheld for at least 24 hours after the cessation of vomiting. During this period,
fluid is given through intravenous drip method. The amount of fluid to be infused in 24 hours is
approximate 3 litres, of which half is 5% dextrose and half is Ringer's solution.

Drugs -
a) Antiemetics drugs
- Promethazine (Phenargan) 25 mg
- Prochlorperazine (Stemetil) 5 mg
- Triflupromazine (Siquil) 10 mg
may be administered twice or thrice daily IM.
b) Nutritional support with vitamin B1, B6, B12 and vitamin C are given.

Diet -
- At first, dry carbohydrate foods like biscuit, bread and toast are given.
- Small but frequent feeds are recommended.

Complications -
- Neurological complications such as peripheral neuritis.
- Stress ulcer in stomach.
- Esophageal tear or rupture.
- Jaundice.
- Deep vein thrombosis.

Vomiting in pregnancy (morning sickness)

Vomiting is a symptoms which may be related to pregnancy or may be a manifestation of
some medical-surgical-gynaecological complications which can occur at any time during
pregnancy. It commonly occur between 5 to 18 weeks of pregnancy.

Causes -
The causes of vomiting is not clear. Several theroies such as increased level of the stomach
contents, increased hormone level, acute fulminating preeclampsia and psycological factors
have been proposed.

Types -
The vomiting related to pregnant state and depending upon the severity, it is classified as :
a) Simple vomiting of pregnancy
b) Hyperemesis gravidarum


                   Simple vomiting (morning sickness or emesis gravidarum)
The patient complains of nausea and occasional sickness on rising in the morning. Slight
vomiting is so common in early pregnancy (about 50% of women) that it is considered as
a symptom of pregnancy. The vomitus is small and clear or bile stained.
It does not produce any impairment of health or restrict the normal activities of the women. 
The features disappears with  or without treatment by 12-14th week of pregnancy.

Management -
- Taking of dry toast or biscuit and avoidance of fatty and spicy foods are enough to relieve
  the symptoms in majority.
- Avoiding food or not eating may actually make nausea worse. Try eating to avoid an empty 
  stomach, which may aggravate nausea.
- Antiemetic drugs- trifluoperazine 1 mg twice daily.
- Patient is advised to take plenty of fluids and fruit juice.


                                        Hyperemesis gravidarum 
It is a severe type of vomiting of pregnancy which has got deleterious effect on the health of
the mother and/or incapacitates her in day to day activities. For details about hyperemesis
gravidarum, visit the following page :
http://pregnancyandlabour.blogspot.in/2014/01/hyperemesis-gravidarum-during-pregnancy.html

Management of normal puerperium

Immediately following delivery, the patient should be closely observed. She may be given
a drink of her choice or something to eat, if she is hungry.

Principles - 
- To give all out attention in to restore the health status of the mother.
- To prevent infection.
- To take care of the breasts, including promotion of lactation and nursing of the child.
- To motivate the mother for contraception.

General management -

Rest and ambulance -
It is indeed difficult to categories an uniform period of rest. After a good resting period,
the patient becomes fresh and can breast feed the baby or moves out of bed to go to the
toilet. Early ambulation is encouraged.

Que. - What is the benefits of early ambulation after delivery ?
Ans. -  Advantages of early ambulation are:
           - Provide a sense of well-being.
           - Bladder complications and constipation are reduced.
           - Facilitates uterine drainage.
           - Hastens involution of uterus.
           - Lessens puerperal venous thrombosis and embolism.

Hospital stay -
Early discharge from the hospital is an almost universal procedure. If adequate supervision
by trained health visitors is provided, there is no harm in early discharge.

Diet -
The patient should be on normal diet of her choice. If the patient is lactating, high calories,
adequate protein, fat, plenty of fluids, minerals and vitamins are to be given.

Care of the bladder -
The patient is encouraged to pass urine following delivery as soon as convenient. If the patient
fails to pass urine, catheterisation should be done. Catheterisation is also indicated in case of
incomplete emptying of bladder.

Care of the bawel -
The problem of constipation is much less because of early ambulation and liberalisation of the
dietary intake. A diet containing sufficient roughage and fluids is enough to move the bowel.
If necessary, mild laxative such as Igol (isopgol husk) two teaspoons may be given at bed time.

Sleep -
The patient is in need of rest, both physical and mental. So she should be protected against
worries and undue fatigue. Sleep is ensured providing adequate physical and emotional support.

Care of the vulva and episiotomy -
Shortly after delivery, the vulva and buttocks are washed with soapwater down over the anus
and a sterile pad is applied. The patient should look after personal cleanliness of the vulval
region. The perineal wound should be dressed with spirit and antiseptic power after each act
micturition and defaecation or at least twice a day.

Care of the breast -
The nipple should be washed with sterile water before each feeding. It should be cleaned
and kept dry after the feeding is over. Nipple soreness is avoided by frequent short feeding
rather than the prolonged feeding, keeping the nipple clean and dry.

Lactation suppression

Suppression of lactation becomes necessary if the baby is born dead or dies in the neonatal
period or if breast feeding is contraindicated.

Mechanical method for lactation suppression -
It may be used in cases where the lactation is to be suppressed after the establishment of
milk secretion.
i) The patient should stop breast feeding.
ii) She should not express or pump out the milk from the breast.
iii) A tight compression bandage is applied for about 2-3 days.
iv) Analgesic tablet containing aspirin and ice packs are given to given to relieve pain and
    breast engorgement.

Drugs for lactation suppression - 
Bromocriptine (dopamine agonist that inhibits prolactin) 2.5 mg, 1 tablet daily for 10-14 days
may be given (with caution).
Side effects are:
- Hypertension
- Rebound breast engorgement
- Myocardial infarction
- Puerperal stroke.
Puerperal breast engorgement though painful, is never fatal.